April 2005, Vol. 15, Iss. 2

Table of Contents

Altered Cervical Lordosis and DJD • Chiropractor Invents Car Seat Headpiece • DACBRs Cause Professional Embarrassment at RAC • Eight Major Aberrant Forms of the Lumbo-Pelvic Spine • European Spine Journal to Publish 6th CBP® Clinical Control Trial • Evidence Based or Not • Glutamate/Aspartame - Pain and Your Brain • Greg Buchanan Donates $30,000 to CBP® Nonprofit • Inappropriate Characterization of CBP® Technique • Missed Appointments and Patient Education • Money, Taxes, Life and Practice • Palmer College Takes Alumni Group to Court • PosturePrint™ Research with ICA • Presenting Defendable Care Options to Patients • Published Papers Near 81 • Resign or be Terminated • Thermography: Renewed Interest • Using Silence to Communicate • Whiplash Injuries: Pathophysiology, Diagnosis, Medical Management and Prognosis

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Counter Point - Round 2

A Further Discussion of the Support for a Connection Between Altered Cervical Lordosis and DJD - Part II

by John McDaniel, DC, DACBSP

Dr. John McDaniel received his DC degree in 1986 from Palmer College of Chiropractic-West. He studied CBP® at that time receiving instruction in the early stages of this technique from Don Harrison, DC in Sunnyvale, CA. After graduation, he followed CBP® protocols for a couple of years but discontinued using them. Since then, Dr. McDaniel has pursued teaching undergrad and continuing ed at Palmer-West, published some literature reviews and case studies, obtained his Diplomat from the American Chiropractic Board of Sports Physicians, served on committees for the CCA and the ACBSP, is the current president of the ACBSP, and maintained a private practice in Mountain View, CA. He has continued to follow the progress of chiropractic research in general and CBP® in particular.

               Certainly, I would like a round 2. However, for this debate we lack judges who will be scoring this discussion. It is up to the reader. I appreciate the opportunity to continue this debate. Debating issues is at the very heart of advancement in any profession.

              I was amazed that you would take the time to provide a response with 79 references for what amounts to a letters to the editor debate. However, a close examination of some of those references would note that many should not be under consideration. Some of the papers are not relevant, many would apply to conditions which are rarely, if ever, seen in CBP® offices and many are quite dated. Some references come from the 1960’s, 1950’s and even one from 1938! It is unlikely that I would be able to find and evaluate the reference to Frechede B, a paper presented at a Spine Research Society Meeting in Porto, Portugal. A couple are listed as, “in press.”

              You can understand my confusion, too, when my use of the term, “ideal spine model” was listed as a significant mischaracterization. I drew that terminology directly from CBP® literature. In fact, appearing on the front page in the very same paper as our discussion and written by Deed Harrison, DC touting the latest published work was this line, “This manuscript is one step in a series of many CBP® biomechanical investigations aiming to determine an ideal spine configuration” (emphasis mine).1 I also note that CBP®’s URL is, “IdealSpine.com” which appears just under the masthead.

              I was similarly confused when my use of Shaikewitz’s reasonably well done article with a poor IRB drew fire. But, then support for CBP® was quoted from a study performed in 1938 which likely did not even have an IRB much less any of the protocols required for a modern study to be accepted for publication!

              I made no attacks, ad hominem or otherwise, on your IRB protocol and never intended to. Dr. Perle is also confused by this reference as he does not recall ever attacking your IRB protocol.2

              I do consider headaches to be a health related disorder. I read those supportive studies and do consider this one area where there exists sufficient proof of the value of lordosis reconstruction to make it clinically valuable. If other, less costly interventions have failed then lordosis reconstruction may be of value in these non-responsive headache cases. I suppose a similar case could be made for this type of use for all neck pain patients. Lordosis reconstruction could be used if other, less costly methods had failed. There does seem to be sufficient evidence for such a cautious approach to this expensive and time consuming process. However, as pointed out in my prior letter, and by yourself in your response, there is nothing to say that a more expensive lordosis correction is better or worse than self limitation or other types of care for neck pain.3,4 I guess we agree, again.

              I realize that degenerative changes after cervical surgery are a serious health concern.4 But, I do not see where the results of a study on those who suffer from serious degenerative conditions following spinal fixation surgery apply to the population normally seen in a CBP® clinic. Those in the studies cited had post surgical complications which caused alterations in their curvatures and increased DJD. Many had extreme cases of DJD or rheumatoid arthritis to begin with. Most were required to undergo a second surgery and/or had a plate installed. These studies did not claim or support the claim that CBP® techniques could have substituted for the first or second surgery nor that CBP® techniques could have stabilized the post surgical collapse of the cervical spine.5,6,7

              Similarly, although Hohl did find a correlation between auto accidents, altered curvature and DJD, he did not say that DJD was due to the altered curve nor that restoring that curve could delay or stop DJD. Norris found, as you say, “abnormal cervical curves...are more common in patients with a poor outcome.” However, you left out the middle portion of that quote. The true quote is, “Abnormal cervical curves, presumably reflecting spasm of the neck muscles are more common in patients with a poor outcome.”18 Both felt a changed curve was merely a sign of the amount of damage done during the accident. Neither noted any causal connection between the altered curve and any other factor.

              Hohl listed several other signs of damage which were correlated with DJD including age, amount of property damage, unconsciousness at the time of injury, length of symptoms, fixations on flex/extend radiographs and use of a cervical collar.8 And, Hohl states, “The much higher incidence of these (DJD) changes in the present series suggests that the trauma was probably a causative factor,” and, “The findings in this series support the concept that deeply lordotic, shallow lordotic, and flat cervical curves are normal variations. A sharp reversal of the curve after injury, however, is a harbinger of degenerative changes in 60 percent of patients.”8 Claiming after the accident restoration of the cervical lordosis can prevent DJD is no more supported by these studies than claiming that avoiding cervical collars will reduce DJD. After all, 63% of those who used a cervical collar for more than 12 weeks showed DJD at follow up.8 I doubt removing those collars at 11 weeks would have stopped the subsequent DJD. Gore supports the connection between injury and DJD in the absence of lordotic changes by stating, “We also found a trend for injured patients with normal roentgenograms at the time of injury to develop degenerative changes more frequently than uninjured patients with normal roentgenograms, indicating that trauma may increase the likelihood of a patient developing roentgenographic evidence of degenerative disc disease.”9

              I doubt there is any controversy surrounding the idea that DJD can cause pain, although not in all cases. The real question regarding CBP® is, “Does kyphosis cause DJD?” Gore’s work does recognize the presence of pain with DJD.9 However, both Gore’s and Shaikewitz’s work rather resoundingly concludes no causation between lack of lordosis, however you measure it, and DJD.9,10,11,12 True, Weigand supposed a correlation between measurable alterations in lordosis and DJD, but this study was performed on a symptomatic population, other pathologies present were excluded, it was not compared to an asymptomatic group and certain assumptions were made which may not be true.13 They began with the assumption that any alteration in lordosis would be the cause of the DJD. This has not been established and is contested by Gore and Shaikewitz’s work. It is equally possible to reverse the conclusions drawn by Weigand from his study and state that DJD causes alterations of lordosis. This was acknowledged by the author in response to questions posed by Lisi in a letter to the editor published some months following the original article.14 There is a third possibility, that they are coincident with each other and related to age.

              Of the remaining citations presented as evidence of the causal connection between altered lordosis and DJD, the vast majority of them were theoretical models (4 of them), post surgical evaluations (5) or very old (1 of them, from 1960). None of these would be considered definitive proof.

              It is true that my opinion, “Adequate pain control can be achieved with less visits and expense by SMT alone as compared to CBP®’s Structural Rehabilitation procedures,” is my opinion. As you stated, “Since this (study) has never been performed, Dr. McDaniel’s statement is neither supported nor refuted and statements like these should not be made.”4

              However, it seems to reflect your opinion. I actually thought we would have agreement on this point. I got some of those ideas from your literature. As an example, a small brochure advertising CBP®’s certification program arrived only a few days after publication of our debate. On the cover is a clear picture of yourself and one of Dr. Don Harrison. In there this quote appears, “Patients are given their choice of receiving (1) Relief Care for their symptoms and/or restoration of functional ROM (usually entails 8-16 visits), and/or (2) Corrective Care for their abnormal posture and spinal displacements (a minimum of 24-30 visits added to the relief care). Relief Care consists of the segmental adjusting techniques the chiropractor prefers to utilize including, but not limited to: Diversified, Gonstead, Activator, Applied Kinesiology, Motion Palpation, etc. While Corrective Care consists of CBP® Exercises, adjusting and traction performed in the Mirror Image®....”.15 CBP® was not mentioned for pain control. A similar statement appears on the IdealSpine.com website.16 A third statement appeared in your reply to this debate. In that letter in response to my request for your ROF under option number 2, you stated, “Relief for her neck pain solely using SMT, myofascial, pnf stretching, ice/heat as needed. This would consist of 12 visits over 3 weeks with an ending re-examination.”4 So, it would seem that it is the written opinion of CBP® itself that relief care with any other technique takes, “..usually 8-16 visits,” where correction with CBP® takes, “...a minimum of 24-30 visits added to the relief care.”

              These statements of yours would seem to be in agreement with mine. If pain control is the goal then this can be accomplished in fewer visits and less cost without CBP®.

              As I have stated, I could see the use of CBP® protocols in non-responsive cases where the suggested 8-16 visits of standard manipulative therapies is inadequate.

              So, we can see that there would appear to be some agreement between us. It would seem that we can agree that the term, “Ideal Spine” is frequently associated with CBP® techniques and therefore not really a mischaracterization. It would seem that CBP® techniques may have some utility in control of headaches and neck pain. It would seem that we both consider such use to be of greater cost and greater number of visits than just about any other technique. We can agree that statements which lack support should not be made.

              There would also remain some controversy between us. Gore and Shaikewitz, the authors of two of only studies truly examining a direct connection between altered curves and DJD, seem to support no causal connection between altered lordosis and DJD. Weigand, the author the third study, would seem to be ambivalent and his opinion subject to revision under questioning. No other direct examinations seem to exist. Some, which you claim provide support, do not truly apply to the patient population seen by CBP® practitioners. I will again defer to the literature and claim that the contention that CBP® techniques promoting an ideal cervical lordosis can alter the course of DJD is both unproven and controversial.

              That would leave the plethora of articles noting some connection between altered spinal mechanics and a variety of disorders. Hyperkyphosis and uterine prolapse is the first one.17 Certainly, a correlation was found but it was not proven causal. There is no evidence that increasing kyphosis causes uterine prolapse and that reversing A will reverse B. Such a claim would require extensive research and support. The same would hold for the other 14 references. Any assumptions otherwise are merely assumptions, and far reaching ones, too. As you, yourself said, “(such a) statement is neither supported nor refuted and statements like these should not be made.” I would agree, again.

              Another notable quote from yourself is, “We have specifically begun addressing this critical level 4 (pain or other health issues) with case studies; of which several are in press/published.” That’s very good. I have always admired CBP®’s devotion to research. However, as stated in my first letter and supported by your own statement above, this is in the works and has not yet been accomplished. So, basing statements on works not yet performed provides neither support nor refutation and statements like these should not be made.

              Again I would note that much of this controversy will be sorted out in the literature over time and currently remains unproven and/or controversial. However, I have a more practical interest. What are patients being told?

              Coming back to the previous theoretical patient, a 45 year old female of average weight with neck pain and a straightened neck, what would be your report of findings? The last one seemed a little short. Certainly if she were offered two choices, relief care with diversified consisting of 12 visits vs. relief care with CBP® consisting of up to 56 visits her choice would be clear. Some other reason must be given to substantiate the need for corrective care. What would that be and what would be the clear, definitive proof supporting that reason? After all, as you’ve stated and I’ll paraphrase, ‘Statements which are neither supported nor refuted should not be made.’

              I realize that this is drifting into practice management but, judging by the mailed flyer noting that your clinic sees 300 PVW, the advertising in AJCC for the, “Chiropractic Biophysics® Hotline,” noting, “Clinical and Practice Management Support,” and, “21st Century Chiropractic Training” with Chris Colloca, DC offering to, “..Transform Your Practice Into a Services and Collections Machine..,” as well as the last page of AJCC and a link on the website stating, “TPMI (Total Practice Management Incorporated) is wholeheartedly endorsed by Dr. Deed Harrison...” it would appear the CBP® and practice management are inseparable.

              I would ask you, Dr. Harrison, do we need a report of findings police?

              1) Harrison, D. The Spine Journal Accepts CBP® Research, AJCC, vol. 15(1), Jan. 2005, pg. 1

              2) Personal conversation, Perle, S. 3/05

              3) McDaniel, J, An Opinion of the Shortcomings of CBP® Technique Research and Practice Protocols, AJCC, vol. 15(1), Jan. 2005, pg. 22

              4) Harrison, D, A Selective Literature Review, Misrepresentation of Studies, and Side Stepping Spine Biomechanics Lead to an Inappropriate Characterization of CBP® Technique, AJCC, vol. 15(1), Jan. 2005, pg. 23-26

              5) Katsuura A, Hukuda S, Imanaka T, et al. Anterior cervical plate used in degenerative disease can maintain cervical lordosis. J Spinal Disord 1996; 9: 470-6.

              6) Kawakami M, Tamaki T, Yoshida M, et al. Axial symptoms and cervical

alignments after cervical anterior spinal fusion for patients with cervical myelopathy. J Spinal Disord 1999; 12: 50-6.

              7) Matsunaga S, Sakou T, Sunahara N, et al. Biomechanical analysis of buckling alignment of the cervical spine: predictive value for subaxial subluxation after occipitocervical fusion. Spine 1997; 22: 765-71.

              8) Hohl M. Soft-tissue injuries of the neck in automobile accidents. J Bone and Joint Surgery 1974;56-A:1675-1682.

              9) Gore D, Sepic S, Gardner G, Murray M. Neck Pain: A Long-term Follow-up of 205 Patients. Spine 1987, 12(1) 1-5

              10) Gore D, Sepic S, Gardner G. Roentgenographic Findings of the Cervical Spine in Asymptomatic People. Spine 1986, 11(6); 521-524.

              11) Shaikewitz M, A Demographic and Physical Characterization of Cervical Spine Curvature and Degeneration. JVSR [Vol. 1, No. 2, p. 1-8]

              12) Gore DR. Roentgenographic findings in the cervical spine in asymptomatic persons. A ten-year follow-up. Spine 2001;26:2463-2466.

              13) Wiegand R, Kettner NW, Brabee D, Marquina N. Cervical spine geometry correlated to cervical degenerative disease in a symptomatic group. J Manipulative Physiol Ther. 2003; 26(6):341-6.

              14) Cervical Spine Geometry Correlated to Cervical Degenerative Disease in a Symptomatic Group, letter to the editor, Lisi, A. and reply Wiegand, R JMPT March 2004 • Volume 27 • Number 3

              15) CBP® technique certification brochure, 2/05.

              16) http://www.idealspine.com/

pages/cbp_technique.htm

              17) Lind LR, Lucente V, Kohn N. Thoracic kyphosis and the prevalence of advanced uterine prolapse. Obstet Gynecol 1996;87:605-609.